Serious concerns raised about senior NHS leaders’ approach to patient safety

  • 18th July 2022

In this blog Patient Safety Learning reflects on a recent letter by Keith Conradi to the Secretary of State for Health and Social Care highlighting concerns about a lack of interest and attention in the activities of the Healthcare Safety Investigation Branch (HSIB) at the highest levels of the Department of Health and Social Care and NHS England.

HSIB is the independent national investigator for patient safety in England. Founded in 2017, its mission is to help improve patient safety through independent investigations into NHS-funded care and to promote learning across the NHS.

In his last day in office as Chief Investigator at HSIB, Keith Conradi issued a letter to the Secretary of State for Health and Social Care reflecting on his experience of leading the organisation. In this blog we reflect on this letter and the concerns it raises about the approach to HSIB’s activities by the Department of Health and Social Care and NHS England.[1]

Lack of attention and engagement from national leaders

In his letter Keith Conradi highlights concerns about the level of attention paid to HSIB’s activities at the highest levels of the Department of Health and Social Care and NHS England, and the consequences of this, stating:

“Successive leaders of NHS England have shown little interest in the activity and potential of HSIB and that lack of emphasis has been adopted by the underlying layers of management.”

He also emphasises the need for the Secretary of State to take a central role in setting an example, urging them to show patient safety leadership and encourage others to do the same.

At Patient Safety Learning we believe that patient safety is not just another priority: it is part of the purpose of health care. Patient safety should not be negotiable. We think that HSIB can play an important role in helping to move towards a learning culture in the NHS, however not without system-wide commitment and support for their work.

We were particularly alarmed by the following comment in Keith Conradi’s letter:

“A lack of NHS England participation delayed several HSIB Covid related investigations and reduced the safety impact of their output.”

This is simply not acceptable. There are over 11,000 avoidable deaths in the UK annually from unsafe care (this estimate was prior to the Covid-19 pandemic) with many thousands more patients seriously harmed each year.[2] NHS England failing to actively engage with the national patient safety investigator ultimately lets down those patients and flies in the face of its vision “to continuously improve patient safety” set out in the NHS Patient Safety Strategy.

Need for a systems approach

In his letter Keith Conradi says, drawing a comparison with the aviation industry, that in most safety critical industries a safety management system is a key component for ensuring safety. This involves taking a systematic and proactive approach to managing safety risks, with accountability at the top of organisations and Boards ensuring safety is considered in all decision-making tasks. Reflecting on the current situation in the NHS, he notes:

“Where safety is conducted well in the NHS, it is because of the drive and enthusiasm of individuals rather than through a state organised structured approach. The Patient Safety Strategy introduced a few years ago makes a positive start to reorganising the safety system and could be even more ambitious by introducing a regulated safety management system.”

He urges the Secretary of State to consider taking a safety management system approach at all levels of healthcare.

Patient Safety Learning also holds the view that we can only truly tackle the persistence of avoidable harm by treating this as a systems issue. We need to think and act differently, to transform our approach to patient safety. In our report, A Blueprint for Action, we set out a vision for this, focused around six foundations of safe care for patients and the practical actions needed to deliver them.[3]

Patient safety leadership at a senior level is key to this, in national bodies, Integrated Care Systems’ and Trusts’. This can happen only if we define the competencies and training for those leading for patient safety, and the governance, standards, and reporting for the organisations they lead. This is a central part of the rationale behind the patient safety standards that we have developed, which are intended to help organisations deliver safe care and embed a commitment to patient safety throughout their work.[4]

Opportunity for a reset

For HSIB, this coming year presents is one of significant change. As a result of the Health and Care Act 2022 it will gain statutory independence, becoming the Health Services Safety Investigations Body, with responsibility for maternity investigations meanwhile being transferred to a new Special Health Authority.[5] [6] We hope that leaders at both the Department of Health and Social Care and NHS England will take this opportunity to reset their relationships with these national patient safety investigators, engaging and actively supporting their activities.

As highlighted in our recent report Mind the implementation gap, a key starting point for this would be to ensure there is a system-wide approach for sharing findings and recommendations from HSIB patient safety investigations.[7] There needs to be system-wide commitment and resources, with effective and transparent performance monitoring to ensure that the accepted recommendations translate into action and improvement.

More broadly, the NHS Patient Safety Strategy states that its vision is “for the NHS to continuously improve patient safety”. With a recently appointed new Secretary of State, Steve Barclay MP, and an incoming new Prime Minister, we have an opportunity to build on this vision afresh. We need our leaders at the highest levels of Parliament, Whitehall, and the NHS to treat patient safety as core to purpose of health and social care.


[1] Keith Conradi, Letter from Keith Conradi to the Secretary of State for Health and Social Care, 7 July 2022.

[2] NHS England and NHS Improvement, The NHS Patient Safety Strategy: Safer culture, safer systems, safer patients, July 2019.

[3] Patient Safety Learning, The Patient-Safe Future: A Blueprint for Action, 2019.

[4] Patient Safety Learning, Developing patient safety standards, 17 December 2021.

[5] HSIB, Organisational transition, Last Accessed 17 July 2022.

[6] Sajid Javid MP, Special Health Authority for Independent Maternity Investigations, Statement made on 26 January 2022.

[7] Patient Safety Learning, Mind the implementation gap: The persistence of avoidable harm in the NHS, 7 April 2022.

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